A CASE OF MELANOSIS. 
BY 
WM. H. FALLS, M.D., 
Cincinnati, O. 
Reprinted from The Cincinnati Lancet and Clinic, 
November 18th, 1882. 
LANCET PRESS PRINT. A CASE OF MELANOSIS 
BY 
WM. H. FALLS, M.D., 
Cincinnati. O. 
Reprinted from The Cincinnati Lancet and Clinic, 
November 18th, 1882. 
LANCET PRESS PRINT.  
Sy.l 'ftp. V- 
Section of Spleen. -1-300. THE CINCINNATI LANCET AND CLINIC. 
479 
<Bt[tgtnal Communications. 
The affection is connected with a peculiar 
diathesis or constitutional tendency, as the depo- 
sition often takes place in different and distant 
parts of the body at the same time, and the 
melanotic tumors are seldom solitary. 
The symptoms of melanosis are not well marked. 
When the melanotic deposit takes place in in- 
ternal organs their presence is often only ascer- 
tained after death. The appearance of the 
subcutaneous tumors or nodules are of great aid 
in the diagnosis of this disease. In the cases 
recorded the symptoms were as follows : a gradual 
sinking of the vital energies, a cachectic habit of 
body, and a dusky ash colored countenance, and 
in some cases a dark discoloration of the skin. 
A marked change takes place in the nutritive 
function, slowly giving rise to emaciation, dropsy, 
feeble pulse and night sweats toward the termina- 
tion of the disease, and where the lungs have 
been affected a black mucous expectoration.1 
The pathology of the disease is uncertain and 
pathologists entertain different views on this 
point. Mr. Paget regards the disease as me- 
dullary cancer with the deposition of black pig- 
ment. Billroth considers all melanotic tumors as 
having the structure of sarcoma or carcinoma. 
Green holds that the majority of the cases are 
melano-sarcoma, and with rare exceptions melano- 
carcinoma. Cornil and Ranvier do not regard 
melano-sarcoma and melano-carcinoma as coming 
under the condition described as melanosis. 
They hold that the tumors are simple melanotic 
masses, and entirely distinct from sarcoma or car- 
cinoma, although generalized in all the organs 
like the most malignant tumors. 
A. Heurtaux, in the "New Dictionary of Medi- 
cine and Surgery," Paris, 1876, Vol. 22, page 48, 
thus describes this disease : "Melanosis is divided 
into two principal varieties, viz : 
I. Benign melanosis. 
A CASE OF MELANOSIS. 
Read before the Cincinnati Medical Society, Oct. 10, 1882. 
This very rare disease was first fully described 
and named by Laennec in 1806. Since the time 
of its recognition as a special disease very few 
cases have been met with, and therefore when a 
new case does occur, it attracts more than the 
ordinary attention of the profession. The disease 
is characterized by the deposition in various tissues 
of the body of a peculiar black or dark brown 
substance which has given origin to the name. 
"It has its seat most commonly in the connective 
and adipose tissues, but is also found, though 
rarely, in the mucous and serous membranes, in 
tendons and cartilage, as well as in the osseous 
system, particularly the bones of the cranium, the 
ribs and the sternum. The organs it most com- 
monly affects are the liver, lungs, spleen, pan- 
creas, lymphatic glands, brain, eye, kidney, 
testes, uterus, ovaries, rectum and mammae. 
Melanotic matter has been detected in the 
blood, particularly in that taken from the minute 
veins of the liver. It is sometimes found asso- 
ciated with cancer and sarcoma, and has a great 
tendency to extend to different parts of the body 
through the lymphatic system. Dr. Carswell 
describes true melanosis as divided into four 
forms, viz. : 
1. The punctiform, in which the black sub- 
stance appears in the form of minute points or 
dots, grouped together in a small space or irreg- 
ularly scattered over a large surface. 
2. Tuberiform melanosis (the most common 
and conspicuous of all the forms) may occur in 
most of the organs and sometimes on serous sur- 
faces, such as the pleura and peritoneum. The 
tumors vary in size from a pin's head to an 
orange; they may be single or aggregated to- 
gether ; in the latter case producing irregularly 
shaped masses of great bulk. 
3. Stratiform melanosis occurs only on serous 
membranes. This form is more frequently met 
with in the horse than in man. 
4. Liquiform melanosis, chiefly found in natural 
or morbid cavities, is met with in consequence of 
the destruction of melanotic tumors and the 
effusion of their contents into serous cavities. 
The accidental cavities in which it has been found 
have been chiefly ovarian cysts. The substance 
deposited is dark, but of different hues, sometimes 
reddish-brown, sometimes of a soot-color, and 
occasionally bluish, violaceous, or black. In con- 
sistence it also differs, some having the firmness 
of a lymphatic gland, others the softness of suet, 
and others again being pultaceous or semi-fluid, 
and these different conditions may all exist in the 
same person at the same time. It is in general 
nearly or quite inodorous, and imparts a temporary 
stain when rubbed between the fingers. 
By Wm. H. Falls, M.D., Cincinnati. 
'l. Simple infectious 
melanosis. 
2. Melanic sarcoma 
or melano-sar- 
coma. 
3. Melanic carci- 
noma or melano- 
car cinoma. 
2. Melanic 
tumors. 
Principal 
varieties. 
Exception' 
varieties. 
Melanic chancroid 
Melanic fibroid 
In the simple melanosis it is simply the deposit 
of pigment in the normal tissues of the organism 
without the formation of new elements. In the 
other varieties the same deposition of pigment 
takes place, but with the formation of new ele- 
ments, which manifest all the malignancy of 
sarcoma and carcinoma. All forms of melanosis 
have a progressive course to a fatal termination." 
The most remaikable case of this disease on 
record is the one which came under Mr. Prescott 
Hewett at St. George's Hospital, London, in 
April, 1856, and reported in full in the London 
Lancet, vol. 1, 1856, p. 657, and in Volume I, 
1861, p. 263. 
In 1850, the patient, George K-, had a tumor 
removed from the right flank by Mr. Lawrence, 
of St. Bartholomew's Hospital. At the time of 
i Tanner's Practice of Medicine and Wood's Practice 
of Medicine, articles on "Melanosis." 480 
THE CINCINNATI LANCET AND CLINIC. 
his admission to St. George's Hospital, April 7th, 
1856, he had melanotic tumors over various parts 
of the body. Some of these were removed by 
Mr. Hewett (at the request of the patient) and 
the patient recovered from the operation and was 
discharged on the 11 th of June. 
On the 14th of July, 1856, he was re-admitted, 
the tumors, remaining at the time of his discharge 
in June, were growing rapidly. He had slight 
ptosis on each side and had loss of motion in the 
right hand and arm and the mouth was drawn to 
the left side. There was also partial loss of sen- 
sation in the right arm and leg, the speech was 
slow and hesitating. On the evening of the 28th 
he died suddenly. The post-mortem examination 
revealed tubercles of mixed melanotic and en- 
cephaloid cancer in various parts of the body. 
Among the parts in which they were found were 
the heart, liver, pancreas, kidneys and the brain. 
The true nature of the cancerous and melanotic 
disease was determined by microscopical examin- 
ation. 
Mr. Oliver Pemberton in his " Work on 
Cancer," refers to two cases of this disease which 
came under his own observation. One occurred 
in June, 1854, and the other in March, 1855. 
Dr. S. D. Gross, of Philadelphia, in his "System 
of Surgery," Vol. I, p. 320, refers to a case under 
his own charge in 1855. At the post-mortem ex- 
amination the melanotic tubercles were found in 
various regions and organs of the body. A 
notable feature in this case was the existence of 
numerous white and grayish tubercles in the 
midst of black showing that the former were in a 
nascent condition, having not yet .undergone the 
melanotic transformation. 
The case which came under Mr. Lawrence, of 
St. Bartholomew's Hospital, and reported in the 
Medical Times and Gazette, of London, February, 
1864, and also quoted in Tanner's "Practice of 
Medicine," page ill, has attracted considerable 
attention. In his patient the disease was well 
marked, and the case which came under my own 
care, was in many respects almost identical 
with it. 
Dr. George Henry Fox, of the College of Phys- 
icians and Surgeons of New York, in his "Atlas 
of Skin Diseases," has very ably presented the 
case which came under the charge of Dr. L. D. 
Bulkley, of New York, in 1875, and which is 
described as Melano-Sarcoma or Melanosis. The 
case of Dr. Bulkley differs from my own, in the 
longer duration (six years) of the disease, but in 
several points very much resembles it. 
The following is the history of the case which 
has been under my charge. Record made on 
April 5th, 1882: 
Samuel Harvey Robison, born in Greenville, 
Ohio, August 31st, 1854, carpenter, married, 
father of three children, only one living. General 
health has always been good and has worked at 
his trade of carpenter since he was sixteen years 
old up to the early part of last February. When 
twelve years of age he had attacks of inter- 
mittent fever, quotidian type, during one entire 
summer. Occasionally since that time he has 
had one attack in the spring, but has had no« 
attacks for two years. For the past ten years he 
has had occasional attacks of dyspepsia. Com- 
mencing five years ago he had an attack of intes- 
tinal colic about every three months. It yould 
come on in the evening and continue all night, 
but in the morning he would be entirely over it. 
These attacks of colic continued for three years. 
In January, 1881, he contracted gonorrhoea, 
accompanied with epididymitis on the left side, 
after a duration of three months he recovered 
from this disease. 
December 1st, 1881, the sight of the left eye 
became impaired, and about the first of February, 
1882, the right eye also became affected. (Report 
later of Dr. S. C. Ayres, of Cincinnati). 
On January nth, 1882, he was sent to Dr. W. 
H. Mussey and myself by Dr. L. G. Lecklider, of 
Greenville, Ohio, for the purpose of having an 
operation performed for the removal of three con- 
genital naevi. Being a man of moderate means, 
he consented to have the operation performed 
before the class at the Cincinnati Hospital, and 
on January 13th, 1882, they were removed by 
Dr. W. H. Mussey. One was situated over the 
angle of the left scapula, and the other two over 
the left sterno-clavicular articulation. At the 
time they were removed they were of a reddish- 
brown color, and quite prominent. They had 
remained about the same size for a long time, and 
were removed on account of the clothing irritating 
them and causing them to become abraded. One 
year ago he noticed an enlargement of one of the 
glands of the left axilla, it gradually increased in 
size up to two months ago, but since that time 
has not enlarged. With the exceptions of the 
diseases stated he has always enjoyed unusually 
good health. 
Family history.-Father died of phthisis pul- 
monalis. During the last sixteen years of his 
life he was afflicted with an epithelioma on one 
of his lower eyelids, and for the four years before 
his death, it gave him considerable trouble on 
account of its painful character, 
Mother living and in good health. Ten years 
ago her left breast became enlarged and suppur- 
ated, more or less, for about one year, when it 
healed and caused no trouble afterwards. 
Has had two sisters and two brothers. All are 
living. No history of consumption or cancer in 
the family except as has been stated. 
On March 10th, 1882, Mr. Robison arrived in 
this city from Greenville and called on me to have 
me accompany him to Drs. Williams, Ayers and 
Sattler, for their opinion and treatment of his 
eyes. I placed him under their care, and he be- 
came a patient of their's in their private hospital. 
On March 15th, 1882, while voiding his urine 
into a vessel, he was told by another patient that 
his urine was of a very dark color. The same 
day he called on me for advice and treatment of 
this condition. Judging from the dark appear- 
ance of the urine, but without giving it an exam- 
ination, I supposed it was a case of haematuria, 
and gave him, 
R Ext. ergot, fl. Siiss 
Tinct. ferri chlorid gss. 
M. Ft. mist. sig. one teaspoonful every four 
hours. 
He continued this treatment for one week and 
then reported to me that he was much better, as 
the urine was not quite as dark in color. At this 
time he was very much constipated and his 
stools were of a yellowish white color, I then THE CINCINNATI LANCET AND CLINIC, 
481 
discontinued the medicine given on the 15th of 
March and gave him 
R Sodii phosphas. i;iii (3) 
S g. One teaspoonful in water 3 times a day. 
I saw or heard nothing of the patient from 
this time until the 6th of April, when my atten- 
tion was aroused to the importance of the case. 
I then made the following notes and observa- 
tions. 
Weight at present is 135 lbs. Has lost fifteen 
pounds in weight since the first of last February. 
Locomotion perfect. Appetite fair. Tongue 
slightly coated with a light brown fur. Bowels 
generally costive. Passes urine freely and it is of 
a dark brown, almost black, color. Abdomen 
bloats frequently and he suffers from occasional 
attacks of water-brash. Irregularly has shooting 
pain through his bowels, and some pain in his 
back over the lumbar region. His strength has 
gradually failed him during the past two months, 
and at the present time he does not feel" able to 
perform manual labor. 
General appearance and physical examination : 
Height, five feet, six and a half inches. Hair of 
head dark brown in color and curly. Reddish 
brown mustache. No beard. Irides gray in 
color. Sclerse of a dark ashy hue. Body only 
fairly nourished. 
Integument of ears, face and neck, and 
mucous membrane of eyelids, nares, mouth and 
fauces is of a dark ashy color. The lips also 
present the same appearance. The integument 
of the trunk and upper and lower extremities, 
with the exceptions named, is normal in color. 
Scattered over the various parts of the body are 
numerous nodules varying in size from that of a 
pin head to a large pea. These nodules are 
thickest on the anterior portion of the trunk and 
on the anterior portions of the upper and lower 
extremities. On the extremities they are more 
prominent in the course of the veins. A few are 
scattered over the scalp, face and neck, one being 
quite prominent on the upper eyelid of the right 
eye. A small number on the scrotum and penis, 
one being very conspicuous on the glans penis. 
To the touch they are hard, and seem to be situ- 
ated in the subcutaneous tissue, the integument 
being freely movable over them, except those on 
the anterior part of the trunk. Several of them 
are flattened and the integument is not as freely 
movable over them. I should judge, with a rough 
estimation, that there are at least two hundred of 
these nodules on the body. 
Physical examination. Heart and lungs nor- 
mal. Abdomen prominent. Liver enlarged, the 
hepatic dullness extending three inches below 
the margin of the ribs. Splenic dullness increased 
about two inches in each measurement. Some 
tenderness over the spleen, but over no other 
portion of the abdomen. 
Pulse 80. Temperature F. 
The patient states that these nodules first made 
their appearance on the right shoulder, during 
the latter part of January, 1882. 
As they were not painful and had only grad- 
ually increased in size and number, he had not 
thought it necessary to say anything to me about 
them, or to call my attention to them. When he 
first noticed them they felt about the size of a 
small pin head. 
lie states that the discoloration of the skin 
first made its appearance about one week ago, 
and that it has gradually become darker in color. 
He now states that his family had occasionally 
noticed during the past two months the dark ap- 
pearance of his urine but he himself had paid no 
attention to it. 
The urine was examined by Prof. Joseph 
Eichberg of the Miami Medical College with the 
following results. 
" Urine very highly colored, almost black. On 
standing deposits a very abundant, dense and 
heavy dark brown precipitate. The super- 
natant liquid becoming perfectly clear and ol a 
dark amber color. 
Reaction faintly acid. Sp. gr. 1018. 
A very peculiar sweetish odor. Some albumen. 
Microscopical examination shows sediment to 
consist largely of casts of a dark brown color, 
finely granular, without definite cellular elements, 
although here and there an epithelial cell may be 
seen adhering to the cast. 
In addition there is a large quantity of an 
amorphous powder (urate of soda), and a few 
altered red blood corpuscles. There are also found 
some cells of bladder epithelium covered with 
the amorphous powder." 
The case presenting the history and symptoms 
stated, the important question presented itself: 
What is the disease ? 
The possible diseases coming under a differen- 
tial diagnosis were Addison's disease, melanae- 
mia, chloasma, argyria, and melanosis. 
The dark discoloration of the skin pointed very 
strongly to Addison's disease, but taking into 
consideration the black urine, the sudden and 
rapid discoloration of the skin, and the nodules, 
with the absence of anaemia, progressive emacia- 
tion and gastric irritation, I decided it was not 
Addison's disease. 
The splenic enlargement, dark urine and dis- 
coloration of the integument were indicative of 
melansemia ; but the absence of malarial fever, an 
elevation of temperature, intestinal haemorrhage 
or marked brain symptoms, and the presence of 
the nodules, excluded this disease. 
It could not be regarded as a case of chloasma 
merely, for with the change in the color of the 
integument, other important conditions were pre- 
sent not found in cases of simple chloasma. 
Is it a case of argyria ? On questioning 
the patient I ascertained that he had not taken 
any of the preparations of silver, and therefore 
argyria was not to be regarded as the disease. 
Having carefully considered the history which 
I have given, and the symptoms which I have 
stated, and observing their marked similarity to 
those in the cases of melanosis which have been 
recorded, and being satisfied with my differential 
diagnosis, I pronounced the disease to be melanosis. 
Prognosis unfavorable. 
Treatment. Supporting and palliative. 
He remained in the city until April nth, and 
then returned to his home in Greenville. 
Before returning home I placed him on the 
following treatment: 
R. Pil. ferri carbonatis. grs. v. (5). 
three times a day ; also 
R. Granul. acid, arsenious, gr. fa, 
three times a day. 482 
During his stay in the city, subsequent to the 
time I gave my diagnosis, he was seen by several 
of the physicians of the city. Among the num- 
ber who saw him were Drs. W. H. Mussey, 
Williams, Ayres, Sattler, Clendenin, Carson, A. 
S. Dandridge, Mackenzie, Eichberg, and Hart- 
well. 
Dr. S C. Ayres has very kindly furnished me 
with the following records of the case while 
under his charge : 
S. H. Robison, set. 27, was first examined 
March nth, 1882. His vision was very imper- 
fect, being barely equal to seeing shadows of the 
hand with the right eye, and counting fingers at 
4Z with the left. .An inspection with the 
ophthalmoscope revealed extensive detachment of 
the retina in both eyes. In the right eye the re- 
tina came very far forward below and on each 
side so as to obscure the optic disc. In the left 
eye the detachment was not quite so ex- 
tensive. The retina was still quite clear in both 
eyes, showing that this condition was probably 
recent. He said that the left eye failed first 
about three months ago, and the right in about 
two months later. He states that he had worked 
in a lumber mill, and had done heavy work, 
hoisting boards through a hatchway. It taxed 
his strength to lift the load, and then he had to 
watch and see when he had it up far enough. In 
this way there was a constant strain on his eyes 
as well as on his strength Before engaging in this 
work his eyes were always good, and he was not 
near-sighted. He seemed somewhat broken in 
health and depressed on account of his loss of 
sight. 
He was placed on the hypodermic use of pilo- 
carpine, beginning with gr, and running up 
to | gr. He bore the treatment very well, and 
was not depressed by its effects. It did not cause 
much sweating, but excited profuse salivation. 
His vision was markedly improved within the 
first few days. 
March 14th. After two injections he counted 
fingers at ioz, left eye. 
March 17th. After four injections he counted 
fingers at I4Z, left eye, and 3Z right eye. During 
the second week of treatment he improved slightly,. 
but during the third and fourth weeks he re- 
mained stationary. In two weeks after admis- 
sion I noticed that his skin had a peculiar color 
resembling that which comes from the internal 
use of nitrate of silver. 
March 15th. He complained of some difficulty 
in micturition and asked me to look at the urine, 
which he had passed that morning. Judging 
from its color I should say it was half blood. 
He said that before he came down his friends at 
home noticed the same condition. His sight was 
so imperfect that he could not see the color of his 
urine, and was consequently unaware of anything 
abnormal in it. As he had formerly been under 
the care of Drs. Mussey and Falls, I thought it 
better to ask Dr. Falls to see him. During the 
rest of his stay in the hospital his skin grew 
perceptibly darker and darker. He soon pre- 
sented a cyanosed appearance as if the blood was 
imperfectly aerated, but gradually the pigment 
in the skin became more pronounced, and was as 
dark as that of a mullatto before he left. 
For the subsequent history of the case, I am 
THE CINCINNATI LANCET AND CLINIC. 
am greatly indebted to Dr. L. G. Lecklider, of 
Greenville, Ohio, Mr. Robison's home physician. 
He corresponded with me and kept me informed 
of the progress of the disease ; and very faith- 
fully attended the case to its termination. 
Under April 20th, 1882, he made the following 
notes. The discoloration of the skin has gradu- 
ally passed over the trunk and extremeties and 
the entire body now presents a dark brownish 
color. The parts exposed to the light viz, the 
head, face, neck and hands are much darker than 
the other parts of the body. 
Temperature 98J. Pulse 7O. Appetite fair. 
Urine is still of a blackish brown color. On ac- 
count of sleeplessness at night he was given 
B-Ext. Piscidia. Erythrinae. Fl. 3L 
At bedtime. 
During the month of May no important changes 
in his condition occurred, except that the in- 
tegument has become much darker and is be- 
coming more so every day. His general health 
is about the same as during the past month. Has 
occasional attacks of headache which are relieved 
by 
B-Quiniae Sulphas, grs. ij. (2) every three 
hours. 
On June 1st, 1882, I visited Greenville, and 
saw the patient in consultation with Dr. Leck- 
lider, and was surprised to see the marked change 
in his appearance. The ashen hue of the skin 
and mucous membranes noticed in April has now 
become of a chocolate brown color, and the skin 
is almost as dark as that of the negro. 
The finger and toe nails are dark gray in color 
and the mucous membrane of the urethra pre- 
sents a brownish tint. Vision is almost entirely 
gone. Can distinguish between day and night, 
but nothing more. Passes daily about two and a 
half pints of dark brown urine. 
June loth, 1882. No marked changes, contin- 
ues about the same. Has exhausted his supply 
of pills ordered on April nth and was now or- 
dered 
B-Pit Quiniae Sulphas, grs. ij. (2) every 
three hours. . 
June 27th. Has complained of headache for 
several days, also some pain in upper part of the 
abdomen. This evening ate a very heavy supper 
at six o'clock, and at eight o'clock was seized 
with a convulsion, which continued for about 
three minutes followed by unconsciousness lasting 
about twenty minutes. Half an hour after re- 
gaining consciousness he had a second convul 
sion followed by the same unconscious state as 
after the first one. 
Pulse 75. Temperature 98J0 F. 
Was given B-Potass. Bromid. grs. xx. Every 
three hours, and 
B-Morphiae Sulphas gr. | 
Quiniae Sulphas grs. ij. 
Every three hours. To be given during the 
night. The medicines alternating every hour 
and a half. 
June 28th A.M. Rested well during the night. 
This morning is quite feeble but in other respects 
no change. No impairment of mental faculties 
and no headache. 
Pulse 72. Temperature normal. 
To continue potass, bromid. every six hours and 
to have quiniae sulphas grs. ii every three hours. THE CINCINNATI LANCET AND CLINIC. 
483 
July 1st. No change. Discontinued potass, 
bromid. but quinise sulphas to be continued. 
July 6th. Visited Greenville this afternoon 
and saw the case with Dr. Lecklider. Patient has 
been confined to his bed most of the time since 
the twenty-sixth of June. Has had no return of 
the convulsions. Pulse 80. Temp. 98° F. 
Vision entirely gone and he recognized me by 
voice. The skin and the mucous membrane are 
now of a deep blackish brown color. The 
nodules are more numerous, and those which 
were present early in the disease have increased 
in size. The new ones vary in size from that of 
a granule to a small hazel-nut. 
Urine is still of the same brownish black color. 
July I2th. Has now regained sufficient strength 
to allow him to be around the house and to take 
a short walk out of doors. 
August 5th. This morning about 10 o'clock 
he had another convulsion similar to those on 
June 26th. Previous to the convulsion had com- 
plained of some headache. Treatment the same 
as for the previous convulsions. 
August 12th. Diarrhoea attended with some 
pain. Stools thin and of a dark brown color. It 
was controlled by powders of opium and camphor. 
August 26th. About noon to-day was seized 
with a convulsion. Previous to the convulsion 
complained of frontal headache and pain in his 
bowels. Same treatment as for previous attacks. 
September 9th. Intense feebleness. Has at- 
tacks occasionally of nausea and hiccough. At 
times has frontal headache. Slight oedema of feet 
and legs. Body presents a shruken appearance 
and the color daily becoming much darker. Al- 
lowed milk and lime water to relieve nausea, and 
to have brandy as required. To continue quiniae 
sulphas. 
September 14th. Condition about the same. 
Has paroxysmal attacks of lancinating pain in his 
head. Slightly delirious during the night. Pulse 
80. Temp. 98° F. 
September 15th. Unchanged. Treatment con- 
tinued. 
September 16th. At 4 P.M. to-day had a con- 
vulsion, continuing for five minutes, unconscious 
about twenty minutes. During the convulsion 
the left side of the body was more affected than 
the right. Pulse 82. Temp. 98T75° F. 
September 17th. Some difficulty in deglutition. 
Very restless and refuses to take everything but 
the milk and lime water. A very unpleasant 
odor emanates from his body. Pulse 80. Respira- 
tion 16. Temp. F. 
September 18th. Pulse feeble and slow. Skin 
cool and moist. Passes urine involuntarily. Right 
upper and lower extremities are paralyzed. Deg- 
lution very difficult. Indifferent as to what is 
said or done to him. 
September 19th. Unable to swallow since 
midnight. Pulse imperceptible. Comatose. 
Died this morning at II o'clock. 
Having been notified of his death, I made 
arrangements for the post-mortem examination, 
and on the following day I went to Greenville for 
that purpose. Dr. F. W. Langdon of this city, 
at my request, accompanied me; and we made 
the examination in the presence of the following 
physicians : Drs. L. G. Lecklider, J. E. Matchett, 
O. E. Lucas, Hall, S. H. Jobes, Gard, Miesz, 
Burnett, Lynch, F. Matchett, Stiles, W. Matchett 
Hostetter, all of Greenville; also Drs. Hooven 
and Anderson of Ansonia; Dr. Campbel), of 
Gettysburg, Drs. C. C. Later and Calderwood, of 
Palestine; Drs. Williamson and Fackler, of 
Versailles; Minser, of Webster; Robeson and 
Brumbaugh, of Arcanum; Berry, of Spartans- 
burg; Chenoweth, of Winchester, Ind.; Ruby, of 
Union City, Ind.; Drs. Gray, Smith and Ashton, 
of Piqua; Dr. Beech, of West Jefferson; Drs. 
Hibberd, Driggins and Ballard, of Richmond, 
Ind.; and Messrs. C. W. Roland, George Fry- 
barger and Rev. Crawford, of Greenville. 
Report of necropsy held September 20, 1882, be- 
ginning at 4 o'clock p.m. 
Time: Twenty-nine hours after death. 
EXTERNAL APPEARANCES. 
Rigor mortis almost absent. 
Subject, male; age, twenty-eight years; height, 
five feet, six inches ; fairly developed, somewhat 
emaciated ; anterior surface of trunk, upper ex- 
tremities and face covered with globules of sweat. 
Hair short, wavy, dark-brown, sprinkled with 
gray; a short sandy-red mustache; no beard. 
Hair over pubic region dark-brown. Sclerae 
brownish-yellow, irides yellowish gray. 
Entire cutaneous surface of trunk and extremi- 
ties of a grayish chocolate-brown color, lightest 
on the feet and lower extremities ; the tint grad- 
ually increasing in depth toward the head; the 
color solid and uniformly distributed, without 
mottling anywhere. Face, neck, dorsum of hands, 
and scrotum of a decidedly dark chocolate-brown 
tint, much darker than remaining portions of the 
surface ; feet and palmar surfaces of hands ashy- 
brown ; finger-nails dark bluish-gray; toe-nails 
of a lighter shade of the same color. 
Mucous membrane of mouth and pharynx dark 
ashy-brown. 
The entire cutaneous surface, from the scalp to 
the lower third of legs, irregularly studded with 
numerous projections, due to subcutaneous nod- 
ules, varying from the size of a pea to that of a 
filbert; the smaller ones being chiefly situated on 
the extremities, scalp, and eyelids. These 
nodules were most thickly distributed over the 
flexor surfaces of the extremities and on the an- 
terior surface of the trunk; they were probably 
about one hundred in number on the arms alone. 
On the lower extremities the nodules gradually 
increased in size from below upward; on the 
upper extremities they were more uniform in size 
than elsewhere, averaging about the size of a 
large pea. The right upper eyelid presented two 
nodules, one the size of a pea, the other about 
one-fifth as large; the left upper eyelid contained 
two very small ones, about the size of a pinhead; 
another, nearly as large as a pea, was situated at 
the inner and upper angle of the left orbit. 
The skin overlying the nodules heretofore de- 
scribed was freely movable. 
The anterior abdominal wall was the seat of 
eight or ten nodules, which differed considerably 
in shape from those found elsewhere, being de- 
cidedly flattened or nummular in form and vary- 
ing from a half-inch to an inch in diameter; the 484 
THE CINCINNATI LANCET AND CLINIC. 
skin over these flattened nodules was more or less 
adherent, so that it did not slip over them with 
the same freedom as elsewhere. 
The glans penis presented four small globular 
nodules, two on its superior surface and one on 
either side of the fraenum; the sheath of the 
organ was also the seat of a few small nodules. 
The integument of the scrotum contained about 
a dozen nodules as large as a pea. 
The body presented five cicatrices distributed 
as follows: (1) Overlying the sterno-clavicular 
end of the sterno mastoid muscle, a slightly puck- 
ered cicatrix, half an-inch in length, directed in 
the line of the muscle ; (2 and 3) Overlying each 
sterno clavicular articulation is a similar cicatrix 
also about half-an-inch long(4) At the inner 
border of the left scapula, beginning an inch and 
a half above the angle, is an irregular, puckered 
cicatrix, about an inch in length, directed vertic- 
ally. (These cicatrices occupied the sites of 
three congenital naevi removed by Dr. W. H. 
Mussey at the Cincinnati Hospital, in January, 
1882.) (5) Upon the anterior surface of the 
middle third of the right arm was a linear cica- 
trix, directed vertically, and about one and one- 
fourth inches in length ; (this occupied the former 
site of one of the subcutaneous nodules removed 
by me on April 10th, 1882, for microsco- 
pical purposes). 
The integument overlying and immediately 
surrounding all these cicatrices was more deeply 
pigmented than elsewhere. 
The axillary and popliteal lymphatic glands 
were distinctly enlarged, the left axilla containing 
a nodule as large as an English walnut; the post- 
cervical and inguinal glands were but slightly 
prominent. 
internal examination. 
• 
Cranium : On dividing the tissues of the scalp 
transversely, in the usual manner, they were 
found studded at various points with black, glis- 
tening nodules, of the consistency of tallow, 
varying from the size of a pin-head to that of a 
pea ; these were especially numerous between the 
scalp proper and the pericranium. Between the 
pericranium and the bone and also infiltrating the 
bone itself, were numerous irregular black pig- 
mented areas, inappreciable in thickness, the 
smallest being mere specks, the largest an inch or 
more in greatest diameter ; corresponding to these 
black-pigmented areas the bone was stained in- 
ternally of a deep reddish-brown color. 
The external surface of the dura mater, corres- 
ponding to these black and brown areas, was 
thickly studded with small, black glistening 
nodules, the size of a pin-head and smaller, aggre- 
gated into irregular areas, corresponding to those 
described on the calvarium, and chiefly dis- 
tributed around and in the neigborhood of the 
ramifications of the middle meningeal artery; 
these aggregations of pigment were larger and 
more extensively distributed over the right than 
over tne left half of the dura. The internal sur- 
face of the dura mater was the seat of similar 
areas of pigmented miliary nodules, corresponding 
in situation to those on the external surface of the 
membrane. A few small nodules were scattered 
over the inner surface of the dura mater covering 
the base of the skull. 
Brain : Surface of both hemispheres studded 
throughout with numerous more or less spherical 
masses of black pigment1, putty-like in consis- 
tency, varying from the size of a millet seed to 
that of a filbert; these were situated both in and 
between the convolutions and projected slightly 
above the surface. They were slightly connected 
with the pia mater but so loosely attached were 
they that the larger ones almost fell out of their 
matrix by their own weight. The choroid 
plexuses of both lateral ventricles were exceed- 
ingly dark in color being apparently infiltrated 
with the same pigment as that composing the 
melanic masses. 
The right lobe of the cerebellum was the seat 
of one of the pigment masses which fell out of its 
matrix, leaving a cavity large enough to contain 
a pigeon's egg ; a few masses the size of a pea and 
smaller were scattered over the lower surface of 
the same lobe. 
These melanic masses everywhere in the brain 
were sharply defined, not shading off gradually 
into the surrounding matrix. On section they 
were found to be homogeneous in structure and 
generally dull black throughout; some of them 
however, presenting a central nucleus of a dark 
red color. 
Eye.-The right eye was retained for examina- 
tion at a later time, when the following appear- 
ances were observed. 
Globe much shrunken, and flattened antro- 
posteriorly, having been in alcohol for twenty- 
seven days. 
Sclerotica light brownish yellow in color. 
Iris-yellowish gray. 
On section the anterior and posterior chambers 
were found filled with a brownish-white, homo- 
geneous substance of the consistency of old 
cheese, (coagulated vitreous.) 
Crystalline Lens dislocated downwards and 
outwards, being imbedded in the coagulated vit- 
reous above referred to; color of lens chalky 
white; (due in part at least, to the alcohol). 
Choroid black in color; much thickened, 
especially at inner and upper quadrant, where it 
measured three and one-half millimetres in thick- 
ness ; from this point it gradually diminished in 
thickness in all directions, lining the anterior half 
of the globe appeared on section as a fine black 
line. 
Spinal Cord not examined. 
Trunk: Upon reflecting the integument 
from the front of the thorax and abdomen, 
the subcutaneous adipose was observed to 
be very slight in amount and of a deep 
yellowish color. The underlying muscles were 
of a much darker hue than normal, the tint re- 
sembling that of the heart muscle in the 
condition known as "brown atrophy." 
Scattered throughout the subcutaneous 
and intermuscular conective tissues and 
also invading the muscular tissue itself, 
were numerous small, dark-brown and black, 
glistening, tarry-looking nodules, more or less 
i. The gross appearances of these pigmented nodules 
correspond precisely with those described as "melanic 
masses" by Cornil and Ranvier. (Pathological Histology, 
Phil. ed. 1880, pp. 189-190.) Microscopical examination, 
however, shows them to be cellular in structure, the pig- 
ment being contained in the cells as described in Pro- 
essor Eichberg's report. THB CINCINNATI LANCET AND CLINIC. 
sule tense and glistening. Dimensions: length, 
ten and one-half inches; breadth, six inches; 
thickness (near upper extremity), three and one- 
half inches; weight, three and one-half pounds 
avoirdupois. 
The organ presented the appearance of a mass 
of black nodules ranging from the size of a filbert 
to that of a walnut; the nodular appearance 
being especially marked at the anterior border 
and internal surface of the organ. The external 
surface presented about a dozen flattened, slightly 
projecting circular nodules, varying from half an 
inch to an inch and a quarter in diameter. 
On section, the tissue of the organ was found 
to be increased in consistency, somewhat friable 
and of a very dark brown, almost tar color. It 
was apparently entirely composed of more or less 
spherical nodes, varying from the size of a filbert 
to that of a walnut. 
Kidneys, normal in size, flabby in consistency, 
deep brown in color. Capsule somewhat adher- 
ent, carrying away with it when detached, a thin 
layer of cortex. 
On section, the cortical substance was found 
about normal in amount, of a dark chocolate- 
brown color, and finely mottled throughout with 
black points and streaks; the direction of the 
streaks being from the periphery of the organ 
towards the base of the pyramids. 
The pyramids were plainly mapped out by their 
dark bluish-black tint, increasing in depth to- 
ward the papillae, which were of a tarry black 
color. 
Supra-renaj, Capsules normal in size, 
brownish-yellow in color. 
Urinary Bladder not examined. 
Generative Organs apparently normal in 
development. Both testes filled with black nod- 
ules about the size of peas and similar in consist- 
ence to those in the subcutaneous tissues. (Nod- 
ules on penis and scrotum noted under external 
appearances.) 
Stomach, moderately distended by a blackish 
grumous fluid of the consistency of thin syrup. 
The mucous membrane of the organ was of a dark 
yellowish-gray color, marbled near the cardiac 
extremity with fine black lines. 
Gall bladder moderately distended by a 
dark, tarry-looking liquid of the consistency of 
thin syrup. 
Liver very much enlarged, blackish-brown 
in color; surface glistening and covered with 
flattened circular nodules throughout; the no- 
dules varying from a quarter of an inch to one 
and one-half inches in diameter. Dimensions: 
greatest length, thirteen inches; breadth, ten 
inches; thickness four inches; weight, nine 
pounds, avoirdupois. 
On section the tissue of the organ was found 
somewhat friable and apparently entirely com- 
posed of blackish brown globular nodules, simi- 
lar to those found in the spleen, varying from 
the size of a filbert to that of a walnut. 
The Pancreas was normal in size, presented 
on section a yellowish gray color, and was studded 
with fine dark points. 
Small Intestines contracted in calibre, dark 
gray in color externally. Contents: grayish 
mucus only. Mucous membrane throughout of 
a dark grayish-brown color. No appreciable 
485 
spherical in form, ranging from the size of a pin- 
head to that of a large pea. These nodules were 
much firmer in consistency than those found in 
the brain, preserving their globular form even 
under considerable pressure. They corresponded 
in situation to the projections of the skin de- 
scribed under the head of external appearances. 
In addition to these more or less globular 
masses, there were several flattened masses and 
stratiform collections of melanic matter, the lat- 
ter situated chiefly in the sub-peritoneal con- 
nective tissue. 
Thorax : The ribs presented a few blackish 
pigmented areas similar to those described in the 
calvarium, and corresponding to sub-periosteal 
deposits of pigment. 
Upon opening the thorax, the right pleural 
cavity was found to contain about two ounces of 
a reddish-brown serous fluid. 
The Pericardium was darker in color than 
normal and its cavity contained about an ounce 
of a reddish-brown serous fluid. 
Heart : Normal in size and position, dark- 
ened in color, its walls relaxed and flabby in con- 
sistency; sub-pericardial adipose almost entirely 
absent. Right auricle distended by a soft, yel- 
lowish fibrinous clot; right ventricle contained 
a similar clot, smaller in size; left cavities empty. 
Heart walls about normal in thickness. 
The myocardium, the valvular endocardium, 
and the tunica intima of the great vessels were of 
a dark yellowish-brown color, .darkest in the lining 
of the pulmonary artery ; base of aorta studded 
with light yellowish atheromatous patches in 
strong contrast with the dark yellowish-brown 
color of the intima. No valvular lesion excepting 
opacity due to the discoloration above referred to. 
Lungs : Left lung firmly adherent everywhere 
by old pleuritic adhesions ; the organ small, firm, 
and but slightly crepitant - (carnified lung.) 
Right lung free from adhesions and otherwise 
normal excepting slight hypostatic congestion and 
a calcareous nodule about the size of a pea, situ- 
ated in the centre of the base of the lower lobe. 
No evident increase of pigmentation on section. 
Tracheal and bronchial mucus membrane, brown- 
ish-yellow in color. 
Bronchial lymphatic glands slightly enlarged 
and infiltrated throughout with a blackish, tarry- 
looking deposit similar to that in the subcutaneous 
nodules and brain. 
(Esophagus : Muscular substance dark brown 
in color ; mucous membrane light grayish. 
Abdomen: The peritoneal cavity contained 
about an ounce of reddish-brown serous fluid. 
The greater omentum contained but a slight 
amount of adipose ; presented a brownish discol- 
oration, especially marked along the course of the 
bloodvessels, and was studded throughout with 
glistening dark-brown and black nodules, miliary 
and smaller in size. 
The intestines were of a dark gray color exter- 
nally, contracted in calibre, and displaced down- 
ward into the hypogastrium and pelvis; being 
almost concealed by a blackish, nodulated, tarry- 
looking mass, which upon examination proved to 
be the liver, extending considerally below the 
umbilicus ; transversely, the liver occupied nearly 
the entire width of the abdominal cavity. 
Spleen much enlarged, black in color; its cap- 486 
TUB CINCINNATI LANCET AND CLINIC. 
alteration in the solitary follicles and peyerian 
patches, other than the discoloration referred to. 
Vermiform Appendix considerably swollen, its 
distal extremity being dilated in the form of an 
oblong cy«t about one inch in length, and half an 
inch in diameter, filled with a clear, brownish, 
gelatinous substance. 
Large Intestine contained a moderate quan- 
tity of semi-fluid faeces, dark bluish-gray in color. 
Mucous membrane dark grayish-brown. 
Rectum filled with pultaceous faeces of a dark 
bluish-gray color. 
Mesenteric Glands enlarged, varying from 
the size of a pea to that of a filbert, and filled 
with black pigment of the consistency of putty. 
Retro-peritoneal Lymphatic Glands, like- 
wise enlarged and filled with black pigment. 
microscopical examination. 
On April 1 ith, 1882, I removed one of the 
subcutaneous nodules from the right arm, and 
gave it to Prof. Joseph Eichberg, Pathologist to 
the Cincinnati Hospital, for microscopical exam- 
ination, the following is his report: 
"The nodule is situated in the subcutaneous 
cellular tissue, which is thickened and condensed 
around it, though not forming a distinct capsule 
completely around the growth. 
Microscopically the nodule measures in length 
one-half inch and is one-third of an inch deep at 
the widest part. It presents a uniform dark 
brownish black color, and to the naked eye ap- 
pears to be perfectly circumscribed. 
On microscopical examination with a low power 
the tumor presents an almost characteristic alveo- 
lar appearance, such as is found in carcinoma, 
with several bands of spindle cells traversing it in 
different directions. 
The cells are nearly all more or less deeply pig- 
mented, the pigment being deposited in the form 
of fine granules in the protoplasm of the cells, 
but not in the nucleus; (this with Hartnack Ocu- 
lar No. 3, obj. No. 4.) 
The surrounding connective tissue presents the 
appearance of cedematous infiltration into which 
small groups of cells from the nodule extend in 
different directions, usually maintaining their 
connection with the main part of the growth. 
With obj. 8 and ocular 3 Hartnack, the struc- 
ture of the growth becomes more apparent, the 
staining fluid, Haematoxylin, aiding materially in 
the recognition of individual cells, staining the 
nuclei of a dark violet color, and not affecting the 
protoplasm of the cell. 
The alveolar arrangement recognized by the 
low power now becomes clearly evident, the cells 
of which the alveoli are composed being irregular 
in shape, with large prominent nucleus and nu- 
cleoli; many of them contain several nuclei, and 
all are of the epithelial type. Bands of spindle 
cells are found in one or two places between the 
alveoli, the spindle cells containing no pigment. 
A small round celled infiltration surrounds some 
of the larger bloodvessels in relation with the 
growth. 
The length of the larger cells is thirty micro- 
millimeters, the nucleus measuring six micro-mil- 
limeters. (I of a me- 
ter or of an inch. 
The growth belongs to the class of what are 
commonly known as melanotic tumors called by 
Rindfleisch sarcoma carcinomatodes, and by 
Bilroth an alveolar sarcoma. From its situation, 
and the character of its cells it is undoubtedly a 
sudoriparous gland that has taken on the diseased 
action. This will explain in part the epithlial 
type of cells so marked in this nodule." 
I presented Professor Eichberg with sections of 
the various specimens obtained at the post-mortem 
examination, and requested him to examine them 
microscopically. As the result of his labors he 
has given me the following very able and inter- 
esting report. 
" The Spleen : On microscropic examination 
of the section the spleen presents an appearance 
of distinct nodules deposited in tissue of a uni- 
formly brown color; these nodules vary in size 
from the most minute deposit to the size of a 
filbert. They seem to be distinctly encapsuled 
and their boundaries can be recognized by the 
naked eye, they being much darker than the sur- 
rounding tissue. The microscope shows the dark 
discoloration to be due to a deposit of pigment, 
which is so dense in places as to render the tissue 
completely black and opaque. It is seen that the 
increase in size of the spleen is due partially to the 
nodular deposit, partially also to a very extensive 
and general increase of the stroma ; the increase 
of the stroma being mainly due to the develop- 
ment of a large number of spindle shaped cells 
with very large spherical nuclei, resembling in 
every particular the normal spindle shaped con- 
nective tissue cells found in the stroma, save that 
their protoplasm contains large deposits of a 
brownish granular pigment. The fibres of the 
connective tissue are also increased, and this in- 
crease is most marked in the thickened capsule 
and around the arteries. In the broad band of 
fibrous tissue constituting the capsule are seen 
large numbers of these spindled shaped cells, 
which alone contain the pigment, the fibrous 
tissue being singularly free of all deposit. The 
only traces of normal tissue, as shown by the 
hematoxylin staining occur in the immediate 
vicinity of the large arteries and constitute small 
islands of a diameter of 40 micromillimeters. In 
other places the tissue seems somewhat similar to 
that normally found, but the cells are stained a 
mahogany color ; this staining is not due to pig- 
mentary deposit, but is rather such a staining as 
would be occasioned by imbibition of fluid. 
Whether these cells are of new formation or are 
the original cells altered by the diseased process 
it is impossible to say. The nodules present in 
places the same alveolar arrangement that charac- 
terized the subcutaneous tumor, the alveoli 
consisting of a varying number of large cells 
closely packed together, and richly charged with 
pigment. The cells here are more uniform in size 
than those found in subcutaneous nodule, are not 
quite so large, but still preserve the epithelial 
type, and contain large, well-defined nuclei where 
the nuclei are not obscured by the granular 
deposit. Numerous bands of parallel fibres and 
of the spindle cells already described pass through 
the nodules, separating groups of alveoli from 
each other; the spindle cells always carrying 
pigment. The normal bands of unstriped mus- 
cular fibres and connective tissue are partially 
preserved and comparatively free from pigment. THE CINCINNATI LANCET AND CLINIC. 
487 
The large nucleated cells are found isolated and 
in small groups outside of the nodule, lying in 
the midst of brown colored cellsand stroma, some 
being more others less deeply pigmented. No 
sign of malpighian tufts in any of the sections 
made. 
(The sections were all obtained from one portion 
of the spleen, about | inch cube in bulk.) 
" Lymphatic Gland: Very little normal tissue 
is to be found in a section of the lymphatic gland. 
As in the spleen nodules of dark color are found 
in a uniform brown tissue, the capsule is thickened 
and shows an increase of fibrous tissue, with 
development of numerous spindle shaped cells, in 
which the pigment is deposited. In the nodules 
are recognized large cells, round or polygonal in 
outline with distinct nucleus, occasionally grouped 
in alveoli. The walls of the blood vessels are 
thickened but the connective tissue surrounding 
them is devoid of pigment. Many lymphoid cells 
have a transparent brown staining as in the spleen. 
It is noticeable that the pigment cells and the 
nodules are most abundant beneath the capsule 
the inner surface of which shows a great increase 
of white fibres. Some pigment is deposited free 
in the connective tissue, forming fine spherical 
granules. 
" Kidney is comparatively free ; on microscopic 
examination of the section, dark striae are seen 
to traverse the section in the direction of the 
collecting tubes of the pyramidal substance. 
With the microscope the tubes are seen to be 
almost the only seat of deposit, the pigment 
forming in the granular masses such as were ob- 
served in the microscopical examination of the 
urine. In a few tubes are found brownish-black 
homogeneous casts. Only a few of the tubes are 
affected, the majority remaining free. In the 
cortex the pigment is deposited in the form of 
fine granules scattered irregularly through the 
connective tissue ; the malpighian tufts are free, 
the walls of the arteries thickened, and the 
connective tissue increased as in other organs. A 
few large pigment cells are found in the cortex 
but no trace of alveoli. 
The Eye. Microscopically a large tumor is 
seen springing from the posterior part of the eye 
and apparently circumscribed. The tumor is 
broadest at its base, which follows distinctly the 
normal curvature; at this point it measures | 
inches; its thickness being } inch. With the 
low power of the microscope (Hartnackoc. 2, obj. 
4) the same decided alveolar structure is recognized 
the cells here, however, are much more deeply 
pigmented than in any other tissue save the spleen; 
the tumor is circumscribed, being occasioned by 
a new development limited exclusively to the 
choroid coat, which in parts distant from the 
tumor presents a normal appearance. The sclera 
is normal and not invaded by the new growth. 
The interior of the eye is filled by a mass of coag- 
ulated albumen, enclosing a few indistinct 
fusiform cells. In portions of the tumor which 
have been penciled a very fine meshed net-work 
of connective tissue is easily recognized, the 
meshes being large enough to enclose a single 
cell. The pigment is found almost exclusively 
in the cells which are most deeply pigmented in 
the layers nearest the sclera. The cells present 
yery much the same appearance as thpse found 
in other organs, both as to size and outline. 
The nodule from the brain is distinctly encap- 
sulated, as shown by the way in which it may be 
shelled out of its bed in the nervous tissue. It 
is softer in consistence than the nodules found in 
other organs, even after careful hardening. Its 
structure is essentially the same as that already 
described for; the various nodules, the capsule 
being made up of bands of pigmented spindle 
shaped cells with some white fibres, the interior 
being constituted by alveoli of cells with a large 
number of cells lying closely together but without 
any definite arrangement. In this nodule too 
are found areas in which no definite structure can 
be recognized, in which there is a fine gran- 
ular material with irregular deposits of free pig- 
ment. 
The Liver presented microscopically a uniform 
brown staining with circumscribed nodules of 
dark black color. In these nodules there were 
found pigmented cells and newly formed connec- 
tive tissue as in other parts. By washing the sec- 
tion a great many of the cells were dislodged 
from the alveoli, showing very closely the newly 
formed connective tissue. The portions of liver 
tissue which retained the normal cells were 
obscured. The staining like that already de- 
scribed in the spleen was more of the character 
of a uniform imbibition. 
Skin. A portion of skin obtained after death 
shows a deposit of granular pigment in the con- 
nective tissue of the cutes vera following exactly 
the course of the vessels. It is doubtless owing 
to this that the gradually deepening discoloration 
was due. In summing up all the organs, it seems 
clear that we have to deal with a case of multiple 
melanotic sarcomata, whose microscropic struc- 
ture still shows an alveolar stroma. It is to be 
regretted that the lungs could not be subjected 
to examination along with the organs. With 
reference to the primary growth, supposing that 
all the nodules are of not common origin 
this was probably developed in the choroid, 
which fact would help to explain the melanotic 
character of the secondary growths, it being a 
not uncommon occurrence, that malignant 
growths arising in tissues normally containing 
pigment retain this pigmentary deposit in their 
secondary formations. From the arrangement 
of spindle cells the nodules should be classed as 
sarcomata despite the alveolar character observed 
in all of them. The mode of deposit in the 
kidney seems to be associated with the excretory 
function of that organ, the material being sepa- 
rated not in the tufts, but by the epithelial cells 
of the tubes. 
The great preponderance of pigment in the 
nodules with the immunity of the surrounding 
tissues would seem to point to a selected power 
of tKe cells of the new formations for this granu- 
lar matter. That there must have been at the 
same time disorganization of the blood is shown 
very clearly by the urine which remained of a. 
uniform brownish black color even after the sedi- 
ment it contained had deposited on the floor of 
the vessel, but I venture to advance the hypo» 
thesis that the changes in this fluid were largely 
due to resorption of pigment from broken down 
cells of the new formations; the breaking down 
of the fell allowing th? pigment to become free 488 
and to enter the newly formed blood-vessels, 
whose walls, as in sarcomata generally, were 
formed by these very cells; and as already stated, 
the deposit of these granules in the kidney, where 
the epithelium of the excretory tubules seems al- 
most the only part affected would serve to show 
the presence of free granular matter in the blood. 
Why the blood of such new growths should have 
this peculiar affinity for pigment is as difficult a 
question as why there should ever be any devel- 
opment of sarcomata at all, but that such affinity 
exists is proven beyond doubt, and borne out by 
the specimens obtained from this patient. The 
fact that the first specimen of skin removed during 
life has no deposic of pigment in the cellular tis- 
sue like that obtained post-mortem would be fur- 
ther confirmatory evidence of this theory, the de- 
posit of pigment increasing with the age and 
retrograde processes in the various nodules." 
The following pathological specimens obtained 
from this case were exhibited to the members of 
the society and the medical profession who were 
present. The brain, with the melanic tumors 
and dura mater, liver, spleen, kidneys, testicle, 
bronchial and mesenteric glands, and portions of 
the integument with subcutaneous nodules. 
The author has since presented these speci- 
THB CINCINNATI LANCHT AND CLINIC. 
mens to the Miami Medical College of this city, 
and where those who desire can see them in the 
Museum of the College. 
DESCRIPTION OF PLATES. 
Figure I. From a photograph of Mr. Robison, 
taken one year before the appearance of the dis- 
ease. 
Figure II. Represents the appearance of the 
1 patient on August 1st, 1882, or about fourmonths 
alter the commencement of the discoloration of 
the skin. 
Figure III. Shows the aspect presented by 
the case about three months after the beginning 
of the change in the color of integument. 
Several of the subcutaneous nodules are exhi- 
bited in this figure, but the number which are 
seen is very small in comparison to the large num- 
ber which were present. On account of their 
being situated in the subcutaneous tissue, only 
the larger nodules are seen in the engraving. 
Figure IV. From a drawing executed by 
Prof. Joseph Eichberg. Section of spleen ob- 
tained from a portion of the nodule in which the 
alveolar arrangement is tolerably well marked. The 
section has not been stained. The section has 
been magnified 300 diameters.